Diagnosed April 2021, original PSA 19.59. Gleason Grade 4 + 4, oligometastatic with mets to ribs. Started ADT with Firmagon April, 2021, and Xtandi May, 2021. Didn't tolerate ADT well with extreme fatigue, weight loss, muscle loss, food tastes bad, chronic sinus inflammation. PSMA PET scan in March 2022 revealed that cancer had progressed significantly throughout skeleton in spite of undetectable PSA levels. Dropped Xtandi and completed 6 docetaxel sessions ending August 2022. Recent PSMA PET scan showed most lesions decreased in size/intensity with two sites (rib and hip) showing further progression. Bone pain has returned (was alleviated during chemo treatment), he's lost over 60 lbs and is extremely fatigued. Our MO recommends Pluvicto as a next step, though it is not available in our area and we would need to travel a couple of hours if he is even accepted for treatment. When I read about the radiation risk and think about him getting further fatigued it terrifies me. How do I stay 3 feet away and drive him home from his appointment and provide assistance with standing, etc if his fatigue worsens? It seems an unreasonable risk to caregivers and others in the household. Thoughts?
Is Pluvicto worth pursuing? - Advanced Prostate...
Is Pluvicto worth pursuing?
He can try Xofigo instead. A recent trial found that there is a synergy with docetaxel, and the docetaxel dose can be decreased if combined. The radiation from Xofigo is very short range and doesn't penetrate past skin, so there is no danger from proximetry.
Xofigo seems to be effective for me. I've had three doses so far.
What were the SUV values of the metastases? If the SUV values were below the SUV value of the liver, the response to Pluvicto may be limited. Cancers which do not express PSA most probable have a low expression of PSMA.
If he decides to go with Pluvicto he could request a FDG PET/CT to see if there are mets who do not express any PSMA and in this situation Pluvicto may not be indicated.
He could request a biopsy of the mets to do histological, IHC and genetic studies to see if there are mutations making the cancer susceptible to treatment with Olaparib, keytruda, chemo with platinum compounds or similar treatments.
what is the SUV value of the liver please?
SUV value of liver, if you’re asking for definition, is the uptake of radiotracer (e.g. Ga-68) in that organ. If you’re asking what is the quantitative value, that varies from person to person. So the idea is get the PSMA scan, then see what the SUV values of mets are, relative to the patient’s liver. You want noticeably higher SUV in mets (compared to liver) to get better response from Pluvicto.
You can see my other posting for traveling after Pluvicto.
The distance suggestions are precautions... for driving, they say one in the front and one in the back on passenger side. The main risk is for children and pregnant women. Avoid! For a caregiver, you try to limit exposure as best you can, mainly for the first few days... avoiding it altogether is not required.
For me, the fatigue was quite minor, not at all incapacitating (unlike my 6 weeks of COVID recovery!).
I strongly agree with Tango65 to pursue the FDG scan. In the US, this appears to be less recognized as important as it is abroad, where they have seen failures of Lu-177 that can be -- to some extent -- predicted by the FDG scans.
Mayo nuclear medicine told us that we did not need to be as cautious as I had thought. The main concern is pregnant women and children.
He did need to sit when using the bathroom, close the lid and flush twice, and wash hands thoroughly. Other than his secretions, they were not concerned. We slept in the same king sized bed, and drove home the next day in the same car, next to each other. Once home, he did use a separate bathroom.
They told us that more recent guidelines have loosened up.
for oligometastatic low volume cancer Pluvicto is not recommended as it can be very toxic.
Here is the research paper which explains why is Pluvicto toxic whem applied in low volume prostae cancer.
ncbi.nlm.nih.gov/pmc/articl...
I aldo agree with the other comments above.
> 82 patients were rated as low tumor load, 19 as medium tumor load and 34 as high tumor load.
I scanned the paper multiple times but wasn't able to locate how they classified into 3 groups. I see the examples but no explanation of general logic behind it. Sounds like they did it case by case basis of the 82 sample patients( after exclusions)
OP didn't post latest PSA or details about progression in latest PSMA scan. Its possible they OP might actually be 'medium' and not 'low'
> showing further progression.
You could be right. You made good points. Even for myself I don't know where I would belong.
Most probably I am ultra low volume, but I just don't know.
I definitely don't feel that I would want to Pluvicto myself yet. Radiation sums up.
This makes people with rapidly advancing low volume cancer difficult to decide. The best cancer centers probably have enough experience now, while the others are learning. That is why I believe better not to rush with Pluvicto.
The rating of the tumor load was subjective . They used visual evaluation of the tumor load to classify the patients. See Figure 1.
Our story is similar, same G score and mets in ribs, shoulders, spine and lymph nodes. All ADT failed, 6 rounds Docetaxel followed by 8 rounds of Cabazitaxel, some mets diminished but others grew so considered to have failed. PSA at 50 after all of that plus mega weight loss and total fatigue. We like in France and LU 177, Pluvecto has only just been approved here and is only available in 5 hospitals. We sold our house and moved 8 hours south to be able to get it. So far he has had only 1 treatment, PSA is down to 3, his energy levels are very improved, he has gained weight and has very little pain. We have not had scans yet so don't know the full results but our life has improved so much it's well worth a few days of inconvenience. The radiation levels are extremely low, the risk of cross contamination is tiny providing the guide lines are followed for the first week after treatment. We try to stay a metre apart, sleep separately and his clothes bedding are washed separately but back to normal after a week.
in Germany it was available for a long time. Could not you just simply go to Germany to get the Lutetium PSMA therapy?
We live in France and it was available here - why would we go to Germany? It's completely covered by our insurance in France.
Can you get AC-225 in France? Combine both at lower dose for both. Worked for me at the university of Heidelberg. Heidelberg is close to the French border.
exactly
Coming home from the U of H waiting at the airport in the US customs, two men with Geiger counters found me, detained me while they called radioactive person in DC to see If I am ok or whatever was the reason I was detected on the plane and they were waiting for me. I had doctors letter explaining treatment. Germany has a tolerance where in the US the tolerance is zero. Happened each of four times of my trip.
You want the docs with the most experience.
Even if just for getting second opinions.
Sounds like LU is working out for you so far. Awesome to hear improvements in qol.
Thank you, that is very encouraging!
hi Nellienoodle
We too live in France. Where a ours in France did you move to and which hospitak do you get your treatment from
We live in Roquemaure, not far from Avignon and get the treatment in Nimes. We used to live near Tours.
We are on the Dordogne/Lot border. We have had all chemo sessions and all appointments in Cahors. However we have an appointment with, hopefully new team a week on Monday in Toulouse. Hoping they are more up to date with treatments than Cahors
Toulouse Cancérologie is meant to be very good - my husband had 14 chemo sessions in Poitiers but then ran out of options. I know LU 177 is available in Bordeaux - Bon Courage
I would follow TAs recommendation.
Psma treatments like pluvicto can damage salivary glands and kidneys. No saliva doesn't sound so bad, but may be as bad as the pc. Lots of people spend their last years tethered to a dialisys machine. This treatment can only hasten that. There is good reason they limit the number of treatments you are permitted.
First experiment with adjusting the ADT treatment. Then maybe try bipolar androgen therapy.
Also, before even considering psma treatment, make sure you don't have any non-psma cancer. If all it does is kill part of your cancer, its maybe not worth it.
Yes, pluvicto is a worthy drug for the treatment of prostate cancer. Multiple studies have proven the efficacy of this drug in improving overall survival and quality of life.
For more information, you can read these published articles.
nejm.org/doi/full/10.1056/n.... VISION trial.
DOI: doi.org/10.1016/S0140-6736(.... TheraP trial
pubmed.ncbi.nlm.nih.gov/347.... HSPC-BULLSEYE trial.
pubmed.ncbi.nlm.nih.gov/329...
pubmed.ncbi.nlm.nih.gov/345... Upfront Use of 177Lu-Labeled PSMA Radioligand Therapy and Treatment Response Assessment in Treatment-Naive Prostate Cancer
doi: 10.1097/RLU.0000000000003890. Lu-177 in lymph node metastasis.
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